1. What differences do you note between the two H&Ps?

Compared to my first H&P, my third H&P provides more information regarding the patient’s complaint. Mt first H&P did not include details about the patient’s pain: location, where the radiating pain stops, or if the pain changed over the last few months. Despite the patient’s chief complaint being leg swelling I did not ask any questions concerning her edema. I believe that the HPI would have been better had I included an extra paragraph addressing the patient’s edema before the patient’s pain. My first H&P also failed to include the pertinent positives/negatives in the HPI; I only included this information in the review of systems. For my third H&P, I made sure to include these pertinent positives and negatives in the HPI as well as the ROS.

2. In what ways has your history-taking improved?  Are you eliciting all the important information?

During my first hospital visit, it took me nearly an hour to take down all the history I needed to write my H&P. By my third hospital visit I was able to record my information and perform my physical exam in the same amount of time. I believe that while I am much better at guiding the conversation with my patients and asking the appropriate questions, there are still pertinent questions that I forget to ask. For example, for my third HPI, based on the complaint given by the patient I should have also asked about any recent upper respiratory infections, and how long it takes for my patient’s symptoms to resolve once he stops walking. For the most part I believe I am eliciting the important information, but I need more practice to figure out what extra information I should ask.

3. In what ways has writing an HPI improved? (hint: look at the rubric scores)

Now that I have more experience writing HPIs, I believe that I can ask my OLDCARTS more seamlessly which allows me to write an HPI that flows better. Although my information is organized in my first HPI, the sentences sound choppy. I feel that my third HPI sounds more cohesive and less like I am making a list. Additionally, my third HPI was more detailed compared to my first HPI.  I believe I asked questions more relevant to my chief complaint and I was able to flesh out a better HPI because I knew what questions to ask.

4. What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

When performing a physical exam, I am more confident in my evaluation of the systems we learned during the first half of the semester (skin, head and neck, eyes, ears, nose and sinus, mouth, etc). I had ample time to prepare for this practical and was able to perform my exam on various people. Through constant repetition, I created steps for evaluating these systems and I feel comfortable verbalizing what I’m doing when I see my patients during hospital visits. For the heart/lungs, chest, and abdomen, however, I did not have the same amount of time to practice and was only able to practice on about three people, so I don’t have the same confidence for evaluating these systems. Going forward, I would like to practice these exams on more people and create steps like the ones I created for the first practical exam.

5. Of course, we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

I believe I need to focus on perfecting my physical exam and recognizing what is normal vs what is not normal. Of course, I know this skill comes with practice but at this level, I am not sure what is considered normal, abnormal, or a deviation of normal. For example, in my third H&P I noted that my patient presented with variable sized hyperpigmented brown macules and patches on bilateral lower ankles. With the medical knowledge I currently possess and my patient’s medical history, I wouldn’t feel comfortable concluding that this is benign/normal. In addition, I want to work on being able to determine what labs/diagnostic imaging are appropriate for a list of differential diagnoses. As we’ve learned, labs and imaging should be able to encompass our list of differentials, but I sometimes find myself ordering extra labs that would already be included, for instance, in a CMP or CBC. I believe that with patient scenarios in different classes, I will be able to better hone this skill.